949 EXIT-to-airways for fetal neck mass: extending the procedure to diamniotic-monochorionic twin gestation

Abstract

Fetal airway obstruction in one twin of a diamniotic pregnancy presents unique challenges especially when a single placenta is shared between the fetuses. Very few cases of Ex-Utero-Intrapartum-Treatment (EXIT) in twin pregnancies have been reported, and only in dichorionic pregnancies. We report a single methodology for EXIT-to-airway procedures in monochorionic and dichorionic twins. We review two EXIT-to-airway in twin pregnancies with a giant cervical mass in one fetus. Two cases of EXIT-to-airway in twin pregnancies were performed in 2018-2019 at a regional fetal treatment center. A multi-disciplinary evaluation was completed, and treatment options developed to accommodate parental goals balancing the risks for both fetuses. Case 1 involved a dichorionic-diamniotic pregnancy with a large cervical lymphatic malformation with labor at 36 weeks. Case 2 involved a giant cervical teratoma in a monochorionic-diamniotic twin pregnancy with preterm labor at 29 weeks. In each case, the polyhydramnios caused the affected twin’s amniotic sac to be the presenting sac for the surgical approach. Continuous monitoring of both fetuses was obtained via pulse-oximetry and intermittent transthoracic echocardiography and continuous transuterine echocardiography. Bronchoscopy and intubation were completed after 10 and 22 minutes of uteroplacental bypass respectively. In each case, the affected fetus was transferred to adjacent operating room for complete mass resection. The unaffected twins were delivered as second without intubation and resuscitated without any perinatal distress. Twins and mothers recovered without complications. EXIT-to-airway appears to be a reasonable option for the safe transition of complicated twins even in the setting of significant prematurity in a monochorionic pregnancy. Continuous monitoring permits safe algorithm-based airway management of the affected twin first and subsequent delivery of the unaffected twin. Thoughtful preparation by an experienced multidisciplinary team permits an EXIT-to-airway approach for twin pregnancies in an emergency setting.